Durable Power of Attorney for Health Care, Ohio

STATE OF OHIO

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

OF

____________________________

(Print Full Name)

____________________________

(Date of Birth)

____________________________

____________________________

____________________________

(Address, including County)

I state that this is my Durable Power of Attorney for Health Care and I revoke any prior Durable Power of Attorney for Health Care signed by me. 

I am an adult of sound mind.  After careful consideration, I knowingly and voluntarily make this Durable Power of Attorney for Health Care.  I understand the nature and purpose of this document.  I understand that this is a legally binding document.  If any provision is found to be invalid or unenforceable, it will not affect the rest of the document.   

I understand that this document will take effect only when I cannot make health care decisions for myself.  However, this does not require or imply that a court must declare me incompetent.

I.                    APPOINTMENT OF AGENT

NAMING OF AGENT

The person named below is my agent who will make health care decisions for me as authorized in this document.

Agent’s Name:            ______________________________

Agent’s Current           ______________________________

Address:                      ______________________________

Agent’s Current

Telephone Number:    ______________________________

NAMING OF ALTERNATE AGENT(S)

Should my agent named above be unable, unwilling, or unavailable to make decisions for me, then I name, in the following order of priority, the following person(s) as my alternate agent(s):